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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date S - S -O(p OFFICE USE ONLY <br /> To: San Joaquin County JOB #_ lj'1U REF # <br /> Department of Public Works APN R # <br /> EXP. DATE <br /> S• A Czmk?AkJi VALID S_g-06 TO DRIVEWAYS: <br /> (Applicant Name) STREET '� oe <br /> AREA -.5 -To/U QUAD .S's <br /> 88ZJ`r TN4R.t�c`TbfL1 "R�=� �Ti__A. TYPENcc��t�c�, <br /> (Nailing Address) FORMS. 'R.-29 <br /> NOTE <br /> .STOCYKTON . C4 <br /> (City, State, Zip Code) <br /> X22' yZ� - 22 -77- <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on County- Right-of-Way'oa the side_•of- <br /> B STSZ�.E'T approximately 2*-See mile _ 'aur" <br /> of �l/cNAE� STS �T , by peY€orming the <br /> following work (description of:work) : AUDF s e_FAc 1 Nca THE. A 'FRoOA <br /> 1 EET SOUM14 OF T14 S"fbRrA /-1#1;g TO TP F Y �f/o727'/F B� T,c/F <br /> h�fJ7 i1C h1N'E AAJD ©VE9-I AV GJ/Tk OF AC <br /> Work will commence on or'about for approximately <br /> days. <br /> I, the undersigned certify that I am the owner' of,, the respective property, or am <br /> qualified to represent..the owner and .agree to do .thework described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signature of Appticant Title ate <br /> WkSTBR.pS\FMS®L (6/00) .. <br /> 1 <br />